Amion stands for the question every physician asks at one point or other in their residency – “Am I on?”. As I’ve pointed out before, scheduling is one of the prime candidates for being done externalized – done right by a handful of players, and utilized by everyone else.

Unlike the recent upstarts though, Amion has been around for 15 years. You can read the full story here. And unlike vanity metrics thrown around by other start-ups, Amion probably is used by over 100,000 users, as the company claims. They have products aimed at three user categories -residents, attendings, and organizations. Individuals can schedule their blocks, clinics, shifts synchronized with their personal calendars on external services (like Google Calendar or iCloud). Nuances like shift swaps , didactic pairings are probably what makes it highly relevant product for physician scheduling. Organizations probably value features like the vacation request management, policy-based rules checks, vacation/duty-hour reports, managing last-minute coverage changes etc. Plus there are some logical overlays likes auto-scheduler and template-based scheduling. Last year, Amion announced that they were launching a mobile app in partnership with Doximity. It does make sense that Amion user profiles be powered by Doximity, but the tone of press release seems to suggest more intimacy (scope of which I can’t understand).

For those who dismiss scheduling as a calendering feature, not a product by itself, think again. Here is the rough categories of solutions aimed at the scheduling puzzle in healthcare:

Chances of consolidation? Sure. But more likely are acquisitions by incumbent EHR technology players. Either way, it’s fascinating to see the breed of solutions as evidence for the inherent complexity of delivering timely, coordinated care.

November 2013 Update: Stuart Karon from Amion was kind enough to reach out and explain the Doximity-Amion relationship. Seems like it started with Doximity pulling schedule data for it’s users from Amion. They ended up spinning that part off into an independent app (for Amion). That way Amion got a professional mobile app with minimal investment and Doximity got a channel for getting new users onto the network. Symbiotic…

It’s not often that non-healthcare startups make it to the review list at Multiplyd. But the recent news about cloud storage mega-startup Box moving into healthcare is too tempting to ignore. Let’s first talk about what Box does, and then dissect it’s applicability to healthcare.

Box is a cloud storage, file-share-and-sync company. It claims more than 8 million users and has taken about $284M in funding so far (yeah, that’s right.. >quarter of a billion). With that kind of hormonal surge, it wants to grow up. Fast. And become an enterprise storage company, beating some of its rivals to the punch.

Last month Box announced that they are embracing healthcare, HIPAA and all. “That’s gutsy..” was my first thought. It’s about time we created some of the fundamental building blocks for modernizing healthcare IT – storage, communication, mobility, scheduling, collaboration, pricing, discovery, to name a few on my wishlist. No doubt we need broad disruptions like this in healthcare. If companies like Box solve a fundamental infrastructure problem like storing PHI in a device-agnostic secure platform, it’ll take away some of the complexity of developing for healthcare. More innovation will certainly ensue. The healthcare partnerships Box kicked off with are already some of the young disruptive startups in the field.

To make this a balanced analysis, let’s see the if there are other points to consider. And to do that I’ll put on my traditional health IT hat, deformed and stained as it may be from having worked with EHRs and HIEs for more than a decade.

1. Workflows – Storage is fine. But what about the darn workflows that get/put things in that storage? The ER visit that needs access to your cloud-stored Medication will also need to reconcile them somewhere. And once that is done…. ahem…. in the EHR, it’ll probably need to be updated back in the cloud storage (perhaps Blue Button can help, but it’s not quite there yet in terms of adoption). My point is that without workflows, it’s a bit like taking your hard disk to work/vacation instead of laptop. And whether we like it or not, 95% workflows in healthcare today are done on incumbent EHRs. I’d like to see Box become vendor of choice for some of the multimillion enterprise EHR systems. Then we’ll really be making a dent.

2. Content ownership – Storage may assume clear ownership of what’s being stored. We wish, but it’s not that simple in healthcare. Some first-hand experiences at IDS like Kaiser have proved to me that DURSA is a synonym for chaos in healthcare. Is everything owned by the patient? Yes? Then why don’t all patients carry home their entire medical records? Perhaps it’s the hospital that owns it? Maybe the insurance company? The answer is anything you want it to be. What complicates it further are nuances like consent (which is a conundrum by itself) and state jurisdictions (Exhibit A – if the patient has Anthrax, which is state notifiable disease and a public health risk, the state owns the information regardless. Exhibit B – how to give break-the-glass type access during an emergency). My point is not that this is insurmountable. Only that the number of dials and knobs needed in a healthcare content dashboard and administration is an order of magnitude higher that any other industry.

3. Mobile access – This is where Box’s vision may shine. The inherent complexities and convolutions of healthcare may start to fade when tempted with the mobility value proposition. Your neighborhood endocrinologist values family dinners and golf outings as much as you. So anything that lets him/her easily get to the information he needs, will get traction. A platform that centralizes information and makes it available on-demand, in device-independent way will be appreciated. Incumbent systems like EHRs can have their own flavors (Exhibit A: Haiku) but we may still need a neutral party to do the data arbitrage with smart features like device pinning.

4. Collaboration – Sharing links not files, version control, discussion threads, tasks, etc. are worth doing in a consistent way across applications. So Box can bring value here too. But this featureset is less about technical prowess and more about business development. The more applications Box can bring to it’s platform, more sticky it becomes. Interoperability is undoubtedly the next frontier in healthcare IT, and everyone in the traditional industry is solving it using byzantine standards like IHE, HL7. Maybe there is a simpler way.

Ah, ‘Simple’. It’s uncanny how that word keeps coming up when talking about Box. Not all of it can be credited to its elegant offering though. I think the technology world around us has grown like foliage in an amazonian rainforest. Continuous barrage of super-specialized, hyper-ambitious offerings takes its cognitive toll. Try to browse the startup listings on AngelList, for example. Hybrid taglines (“Mint.com meets Groupon” is one) sound cool but I still have to repeat it few times to understand what the company does.

My point is that simple visions are starting to stand out. Maybe that’s why Box is such a media darling. It’s almost like we subconsciously want to believe that a simple approach to storage and content management makes sense. And may be it does. But it’s certainly not a panacea. I’d like celebrate Box’s move into healthcare, but not necessarily as a savior. Smart startups taking aim at healthcare bodes well in general.

Like in the 80’s Sun Microsystems made a splash with it’s prophetic tagline “Network is the computer“, I believe the next transformational wave in healthcare IT thinking is going to be about the network (read exchange, analytics, population). Time will tell if the cloud storage value proposition survives on it’s own in healthcare.

PS: Interestingly enough, it seems like Sun was considering “Network is the disk drive” as the slogan first, according to this article. Apparently that didn’t capture the intent. Not then, not now.

I know nothing more about Careticker than what their spartan website says. But the first time I read it, something clicked. Careticker is a sort of personal (health) productivity app that lets users manage their interaction before, during and after hospital stays. I think that is a great niche.

Except for hypochondriacs, no one likes hospital stays. Most of the anxiety related to a hospital stay can be attributed to the fear of unknown. Patients simply dont know enough about what they need do or what is going to be done to them during that stay. It’s like visiting a foreign country with no map or translation tool. That, is where I think niche context-aware companion apps can help. For common inpatient procedures (like hernia, tonsillectomy, etc.) a focused mobile app that gives patients reminders, education, to-do lists like functionality is a tremendous value proposition.

Note the word ‘focused’. That’s the key. There are plenty of WebMD, MedlinePlus like generic health information apps that have wide variety of conditions covered. But to make the experience worthwhile the app needs to align all interaction vectors and focus on one intervention (or a group of closely-related conditions/procedures). Take a look at the list of most common procedures performed in US: all of them are candidates for an app. An app to remind patients when to stop eating/drinking for surgery, what to expect during stay, read FAQ posted by surgeon, get a copy of handout/discharge summary, etc. etc.

Back to Careticker. It surprises me that with the fundamentals rooted in an interesting niche, why did they pick a generic, already-crowded-with-apps condition of pregnancy as their first product. To be clear, Ob/Gyn is surely the right subdomain since the majority health-related app user skews to female gender. But a sharper focus (like Caesarean section) may have been smarter. The slightly derogatory name ‘Knocked Up’ doesn’t help either.

There is definitely room for growth in the target market. Especially since outpatient surgeries surpassed inpatient a couple of years ago. For a service like CareTicker, the gamut should run all types of procedures, regardless of care setting. Watch out for more entrants in this space.

The personal wearable-sensor devices trickle that started with FitBit around 2008 is now starting to look like a flash flood. For every one offering that has got media love (like Basis), there are perhaps five other being incubated (like Node).

It’s an embryonic market, and one that is tackling complex health problems with commoditized sensor technology. Every smart inventor in a garage seems to be capable of doing something about it. So a few things are bound to start happening now:

Sandalbay Life exemplifies the last. It’s is a young startup (started last last year) at LA-based accelerator StartEngine. Not much information out there about details of the offering, but their aim is to provide a single software platform for manufacturers to leverage. Given the device and format proliferation, it makes sense that someone should try to manage the complexities of dealing with application and network security, cross-platform performance and reliability issues, etc.

“Providing the white-labeled consumer software for manufacturers to utilize”, as Sandalbay Life founder Neil Malhotra puts it in an interview, is smart, since so many of these offerings are from small players. But the big guys are noticing it too. Qualcomm’s 2net platform is going to be close competition. It too, is a cloud-based system designed to be universally-interoperable with different medical devices and applications and provide easy access to the aggregated data.

I’m also not sure how to align it with other platform approaches that are already out there. Biggest one being Microsoft Healthvault. Healthvault may not be white-labeled, but does provides a way for device manufacturers to contribute their data to a PHR. They do have API’s that let a developer get to the unified Healthvault data. Plus they have a fast-growing ecosystem of devices and apps that are integrated with it.

The play for sensor manufacturers to have a common platform for reducing their development cost is valid. Remaining value propositions (single app for consumers, unifying data from multiple devices, giving providers tools to create workflows and insights, etc.) all come with crushing competition. Plus the whole field of personal wellness tracking is too nascent – we need the devices to take a hold in the mass market before aggregating platforms truly become a viable business themselves.

2017 update: Sometime in the last few years, Sandalbay Life has recalibrated its offering to be more about wellness training programs. More about services than data aggregation.

In March 2009, Apple hosted an event to introduce the iPhone OS 3.0 software. What I really found interesting back then was a prototype showcased with Lifescan (a J&J company), where they demonstrated how a user could manage her diabetes using an iPhone-accessory glucometer. It was a much needed evolutionary conceptual leap for a widely-used consumer medical device category.

Turns out that Lifescan apparently did nothing with that concept. Anita Mathew (who gave the demo on Lifescan’s behalf in 2009) decided to take it forward on her own and founded Glooko. The company currently sells MeterSync, a cable that connects your iPhone to five popular glucometers in the market. Users can download the ‘LogBook’ app from iTunes store to document, analyze and share their data.

I’m not an investor (yet), but if I was, I’d put my money in Glooko. This is exactly what the future should start to look like for conventional consumer health devices. Instead of being isolated products that store a limit amount of quarantined information, they need to provide a service that enables longitudinal disease management. For a patient with long-standing diabetes, he/she needs to know how much insulin to inject for covering the meal they are about to have, not what their blood glucose number is. It reminds me of Theodore Levitt’s famous MBA quote “People don’t want to buy a quarter-inch drill. They want a quarter-inch hole.”

For Glooko, the long-term sustainability is directly proportional to how useful and sticky it’s users find the logbook iPhone app. The hardware (Metersync) may be critical at first, but end user experience and market differentiation will come from the software. There is competition, of course. Agamatrix has been in the market with it’s iPhone compatible glucometer, and last year they announced partnership with Sanofi-Aventis that gives them the much-needed commercialization ability. Instead of augmenting diagnosis, another company Cellnovo takes a similar approach with therapeutic insulin pumps. Perhaps we’ll see a synchronized gluocometer-insulin pump offering or an intelligent, symbiotic ecosystem for diabetes devices in future.

I’ve talked about the ‘last-mile’ of remote patient monitoring in the past. Conventional medical devices produce digital manifestations of physiological parameters, but the information collected hardly goes beyond the device itself. We need consumer-oriented medical devices to become monitoring services that automate/transform the last mile for consumers. The future is arriving piecemeal, and sadly enough, it’s not being delivered by the incumbent behemoths of the medical device industry. Withings BP Monitor (which I can personally validate since I use it) enhances the value proposition of a regular BP Monitor for hypertensives. Zeo does the same for people with sleep disorders. Granted these offerings are perfect yet, but all vectors are aligned in the right direction. As for Glooko, look out J&J.